The Public Health Advocate: Pivot (Fall 2020)

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PUBLIC HEALTH ADVOCATE FALL 2020

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PUBLIC HEALTH ADVOCATE A UC BERKELEY UNDERGRADUATE PUBLIC HEALTH JOURNAL FALL 2020 ISSUE

EDITORIAL BOARD EDITOR-IN-CHIEF Subeksha Sharma

PRINT MANAGING EDITORS Kahyun Koh Raneem Rayes ONLINE MANAGING EDITOR Manisha Sahoo DECAL MANAGER Haley Chen EXTERNAL RELATIONS MANAGER Jennifer Kwon

STAFF

COPY EDITORS Caroline Kim Erika Rizal Kaavya Venkat CONTRIBUTING WRITERS Priyanka Athalye Firdows Mujir Ammar Bhaiji Mikkel Nagorsen Mahathi Kandimalla Amy Rich Alishah Khan Sonia Vaze Jill Litman Annie Yang

COVER DESIGN Juliana Lopez

Daily Cal’s Creative Agency

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TABLE OF CONTENTS BRIDGING THE GAP 4 MATTERS OF A MOTHER’S MIND 7 WHY YOU SHOULD WATCH YOUR SCREEN TIME 10 DENTAL HEALTH DURING COVID-19 12 DRIVING UNDER THE INFLUENCE 14 BIDING TIME FOR BIDEN 17 HIV AND THE DEEP SOUTH 20 POLITICAL POLARIZATION AND PUBLIC HEALTH 22 THE RACIST PAST OF KIDNEY SCREENING 24 SUICIDE PREVENTION IN VETERANS 26

LETTER FROM THE EDITOR Dear readers, In January of 2020, the Public Health Advocate’s editorial board chose “Pivot” as this issue’s theme to represent a fresh perspective with the entry into a new decade. At the time, we were unaware how relevant our choice in theme would become. 2020 has been a year of facing and adapting to new challenges, not only for the Public Health Advocate, as we postponed our Spring 2020 issue to the fall, but also for the world as a whole. The COVID-19 global pandemic continues to spread rapidly and has touched the lives of every individual.

The United States has been in turmoil, from devastating incidents of police brutality to escalating political polarization.

In California, increasingly severe wildfires have displaced thousands.

Despite the seemingly endless hurdles, we have found a way to shift and adapt to the new normal. Globally, we have fought the pandemic through collective action and the development of a groundbreaking vaccine. In the United States, a record number of voters participated in the 2020 election, an indication of the heightened drive to enact change in the world today. SB 350 passed in California, an attempt to hold electricity companies accountable for their role in the wildfires.

“Pivot” reflects the work of our contributing writers to address issues in public health that impact us all. In “Matters of a Mother’s Mind” Jill Litman introduces us to the initiatives California is taking to combat the underdiagnosis of maternal mental health issues. Sonia Vaze in “Driving Under the Influence” examines the consequences of the legalization of marijuana amidst a lack of regulatory policy. “HIV and the Deep South” by Mikkel Nagorsen explores the ways in which the HIV epidemic in rural America has been exacerbated by the stigma surrounding it.

As you make your way through this issue, we hope you take the time to reflect on how you will adapt to the challenges to come. Although the world may pivot in unexpected directions, together we will shift along with it.

Your advocate,

Subeksha Sharma

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BRIDGING THE GAP How effective family planning in developing countries can impact environmental sustainability.

BY PRIYANKA ATHALYE

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oluntary family planning services (hereafter VFP services) are an essential collection of culturally appropriate tools that offer women the opportunity to separate sex from childbearing and ultimately achieve their desired family size. Among several other resources, typical VFP services help educate couples on ways they can have safe sex to avoid incidences of sexually transmitted infections and unwanted pregnancies, and allow women the freedom to choose from a variety of modern contraceptives.

Extending women the option to delay or prevent pregnancies is one of the most prudent methods available to help to empower women, ensure that their children are well educated and healthy and reduce maternal and child mortality rates. In addition to these downstream benefits, effective VFP is a humane, choice-based solution to the timeless

issue of unfettered population growth and the resulting worsened effects of climate change.

In reproductive and population science, total fertility rates (TFRs) are measured as the average number of children born to each woman of childbearing age in a particular population. Today, the global TFR rests right around 2.5, though those rates can reach as high as 8 in rural regions across Africa and South Asia. Ultimately, these high TFRs have serious implications for expansive population growth that threatens the finite resources of this planet.

Unfortunately, TFRs are difficult to reduce in regions where women experience significant access barriers to VFP services including lack of knowledge, concern about health effects, religious and political conservatism, poor local funding, cultural stigma and

availability of healthcare providers.

These barriers contribute to a large global unmet need for family planning that disproportionately affects populations in developing countries.

Nearly 40% of married women and up to 77% of sexually active unmarried women in developing countries would like to stop or delay pregnancies but do not have access to any form of modern contraception.

VFP services are the most effective and ethical method of reducing population growth. UC Berkeley Professor Malcolm Potts, a reproductive scientist and fervent advocate of VFP, states that “family sizes cannot fall unless women have the information and means to separate frequent sex from childbirth.” In fact, given that women in developing countries have a widespread preference for smaller families, family sizes fall naturally and

THE GRAPH BELOW depicts fertility decline in multiple countries. Higher income countries such as the US spent decades trying to encourage a fertility decline without legalizing and increasing accessibility to modern family planning services. When these services were made available in countries like Brazil, Bangladesh, and Iran, fertility declines were achieved on an accelerated timeline and with relative ease.

Years for fertility to fall from > 6 children per woman to < 3 children per woman

DATA SOURCE: GAPMINDER FERTILITY DATABASE AND WORLD BANK DEVELOPMENT INDICATORS

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rather quickly once women have access to contraceptives. For example, it took the TFRs in the United States 58 years to fall from 6 to 3.5 when family planning services including modern forms of contraception were completely illegal. In contrast, when modern family planning services were made available in Thailand, it took only 8 years for a similar fertility decline to take place.

This illustrates the critical conclusion that VFP services circumvent the need for restrictive and coercive policies, and help women achieve their desired family size, which is nearly always lower than what women would be able to achieve without modern contraceptives.

TFRs are further contextualized by the replacement fertility rate, or the number of children a woman and her partner must have in order to “replace” themselves in the population without contributing to exponential population growth. Voluntary family planning programs over the course of the last 60 or so years have helped 48% of the world’s population reach replacement level fertility, which is 2.1 children per woman. However, decades of prior population growth builds up such vast demographic momentum that even once replacement level fertility rates are achieved in a population, growth can continue for up to 60 years. Given that the planet’s current population growth rate is already threatening resources and contributing to worsening climate change, working to improve the reach of VFP and help women achieve their desired family sizes are both essential at this time. Professor Potts says that the “global population in 2100 will be determined by the actions we take in the current decade,” and that there is quite literally no time left to waste in slowing global population growth.

Though developed countries release more carbon emissions into the atmosphere, population growth and resulting resource utilization will be concentrated in developing countries in the coming years. These are the regions that already have an inherently higher risk of experiencing the brunt of climate change-related events. As such,

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a fast-growing population size will put pressure on the internal resources of low-income countries and will decrease their tolerance capacity towards such climate change-related calamities.

Additionally, as developing countries are growing in size and are actively trying to urbanize and chase economic growth, they are engaging in reckless consumption and overproduction. Such phenomena will continue to create more CO2 emissions and trap more heat in the atmosphere, ultimately increasing the vulnerability of the planet to global warming and natural disasters. As Professor Potts argues, “it is easier to change the population variable than the climate or consumption variables” when looking at ways to reduce the adverse impacts of impetuous human activities.

In fact, Potts advocates for VFP planning as the most prudent solution to climate change, claiming that condoms are perhaps the most cost-effective way to reduce our carbon footprint.

Our current global population is steadily nearing 8 billion people.

Though non-uniform human behaviors make calculating a planetary carrying capacity for humans inexact, it is unquestionably clear that the Earth cannot sustain such a large population in the long-term. In fact, based on our current ecological footprint, scientists estimate that it would take the resources of 1.5 Earths to provide for the current population, a fundamental impossibility.

The UN estimates that as long as there are no new actions taken to address our uncontrolled population growth, we can expect to add 2 billion more people to our population by 2050. If that were to become a reality, scientists predict we would need 3 Earths to sustain human growth and consumption.

In a 2014 journal article entitled “Getting family planning and population back on track,” Professor Potts provides several population growth scenarios for the remainder of this century. His projections show that if global TFRs increased by just half a child, our population would reach 16.6 billion people by the year 2100. In contrast, if our TFRs fell by an average of half a

child, our population would decrease to 6.8 billion people, a much more sustainable number. These estimates indicate that even extremely small changes in average family size will have significant implications for reduced population growth, an exciting prospect for population scientists and climate change activists.

The urgency of the issue of rampant population growth cannot be overstated, especially given that we are already exceeding our estimated carrying capacity. VFP offers a simple, effective, and ethical solution to this problem.

Unfortunately, VFP services have fallen off the policy agenda in many regions and are chronically underfunded across developing countries. Although there is a viable method available to reduce the burden of excess population growth, it is not a priority among many global and local leaders. Achieving widespread awareness and access to VFP services will require active efforts from public health experts and community health workers who firmly believe that family planning services are an investment rather than an untethered cost. Increasing funding for VFP services across the globe will not just benefit women and children at the individual level, it will deeply impact environmental sustainability and population growth trends for decades to come. 

ABOUT THE AUTHOR

Priyanka Athalye is in her final year at UC Berkeley with a major in Interdisciplinary Studies as well as a minor in Global Public Health. She hopes to continue writing as she pursues a graduate degree and a community health-oriented career. In her free time, Priyanka enjoys singing, spending time with her family, and travelling.

MATTERS OF A MOTHER’S MIND Despite the high prevalence of maternal mental health issues, many women go undiagnosed and untreated. What are healthcare providers doing to combat this issue?

BY JILL LITMAN

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regnancy is not always a joyful period for mothers, as new data shows that maternal mental health problems are quite common.

The California Health Care Foundation found that one in five Californian women suffer from depression, anxiety, or a combination of both while pregnant or after giving birth. Despite

the prevalence of mental health issues in this population, due to cultural stigma and social pressures, few women seek treatment for their condition.

According to a report released by the American Academy of Pediatrics, an estimated 50 percent of women who are depressed during and after pregnancy go undiagnosed and untreated, according

to research cited in the report.

Dana Edgull, a manager in the Maternal Mental Health division of the Behavioral Health Services in Monterey County, often works with mothers who are anxious about seeking help for their mental health issues. “After they have their baby, they think it’s supposed to be the happiest time of their lives, and

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many women feel guilty when they finally have to say, ‘I’m really not doing well’, ‘I’m really struggling’, or ‘I need some extra help right now,” she said.

Perinatal mood and anxiety disorders are the most common medical complication faced by mothers. These disorders occur during the perinatal period, which is the time that a woman is pregnant, and the postpartum period, which is the first year after the baby has been born. These include prenatal and postpartum depression and/or anxiety disorders such as Generalized Anxiety

“IF MATERNAL MENTAL HEALTH CONDITIONS ARE UNDIAGNOSED AND UNTREATED, THEY CAN NEGATIVELY AFFECT THE MOTHER-CHILD BOND AND THE CHILD’S LONG-TERM HEALTH.” Disorder, Panic Disorder, ObsessiveCompulsive Disorder, and Birth-related PTSD; in extreme cases, mothers may develop bipolar disorder or postpartum psychosis. While definitive causes of maternal mental health issues are still unknown, research has suggested that a combination of factors can affect the likelihood of developing a perinatal mental health disorder, such as previous experience of mental health problems, biological causes, lack of support, difficult childhood experiences, experience of abuse, low self-esteem, stressful living conditions and major traumatic life events.

While maternal mental health issues cause negative health outcomes for mothers, they also can severely impede the development of the child.

If maternal mental health conditions are undiagnosed and untreated, they can negatively affect the motherchild bond and the child’s long-term physical, socioemotional and cognitive developmental health.

“If a mom is really depressed, she cannot be fully engaged in her

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relationship with her child, or respond to her child’s cues in a way that supports and meets their needs, and this can impact the baby’s brain development from a very early age,” Edgull said.

According to a study in JAMA Pediatrics, a mother’s depression and anxiety from conception through the first year of the baby’s life is associated with negative developmental outcomes through adolescence. The study found that a mother experiencing depression and anxiety before and after birth was linked with her child experiencing shortfalls in language, cognitive and motor development in infancy.

“Research is showing that when women experience heightened levels of stress during pregnancy, when their bodily systems are constantly inundated with high levels of cortisol, that affects their developing baby as well,” Edgull explained. “What we’re finding is that women who have heightened levels of stress during pregnancy, their children are later on being diagnosed with chronic conditions and hyperactivity disorders.”

The California Department of Public Health (CDPH) found that 21% of pregnant and postpartum women in California are affected by maternal mental health disorders, and the prevalence is even higher within racial minority populations.

People who are Black, Native, or from other communities of color are disproportionately likely to experience negative perinatal outcomes. According to the Center for Law and Social Policy (CLASP), nearly two in five women of color experience depression after giving birth, a rate that is nearly two times higher than new mothers overall. As well, data from the Maternal and Infant Health Assessment (MIHA) conducted by the California Department of Public Health (CDPH) shows that one in four African American and Latina mothers in California reports experiencing some level of depressive symptoms.

“One of the biggest risk factors for developing maternal mental health issues is poverty,” Edgull said. The CDPH found that nearly half of all

mothers living in poverty have maternal mental health issues, and a study conducted by the Urban Institute found that one in nine poor infants lives with a mother experiencing severe depression and more than half live with a mother experiencing symptoms of depression.

Though depression is highly treatable, many low income mothers do not seek treatment; the Urban Institute’s study also found that more than one-third of low income mothers with major depressive disorder get no treatment at all.

In addition to the trauma that untreated maternal mental health conditions can inflict on an individual, they also are often very costly. A 2019 economic analysis published in Mathematica examined the economic impact of these disorders; when following the mother-child pair from pregnancy through five years postpartum, the estimated cost is $14.2 billion for births in 2017 or an average of $32,000 for every mother-child pair affected but not treated. 53% of the total costs, or around $7.5 billion, occurred in the perinatal period. Policy and system barriers have contributed to the incidence of untreated maternal mental health issues and its impacts on children’s emotional and social development; however, growing interest in maternal mental health has led many researchers and public health practitioners to design and implement a variety of interventions.

Within California, the Hospital Quality Institute is leading an initiative to help hospital perinatal staff understand, recognize and effectively respond to mental health issues in the perinatal period. This initiative is aimed to complement the passing of Assembly Bill 3032; a bill that went into effect in January of 2020, AB 3032 requires education of perinatal employees about maternal mental health conditions and to inform postpartum women and families about signs and symptoms of maternal mental health disorders, local post-hospital treatment options, and community resources. Edgull also emphasized the necessity of mental health screenings in the prevention

and treatment process. “There needs to be more screening. Women should be screened during pregnancy and then for 12 months after birth on a regular basis.”

To this end, another recent policy that aims to address the issue of maternal mental health in the state is Assembly Bill 2193, which requires all licensed health care practitioners who provide prenatal or postpartum care for a patient to screen or offer to screen mothers for maternal mental health conditions. Effective in July 2019, this bill additionally requires both private and public health plans and health insurers to create maternal mental health programs. On a federal level, in 2016, the Bring Postpartum Depression Out of the Shadows Act was passed, which includes support for identification and treatment of maternal depression. The bill authorizes the Secretary of Health and Human Services to provide federal grants to states for the purpose of screening, assessing and treating PPD, and these grants allow states to create, improve or maintain programs around maternal mental health and help women who are pregnant or recently postpartum.

Edgull highlights the need for legislation that mandates paid parental leave. “It’s ludicrous that on average, in the United States, a working woman gets 6 weeks off following a regular

“AB 302 REQUIRES EDUCATION OF PERINATAL EMPLOYEES ABOUT MATERNAL MENTAL HEALTH CONDITIONS...” vaginal birth, and 8 weeks for a Cesarean section,” she said. “I would say that I would consider universal paid maternity leave policy to be a top priority for lawmakers.” Unlike other developed countries, maternity leave coverage in the United States has been provided primarily through employer policies and is not required in many states. Research shows that paid maternity leave promotes greater bonding between mothers and

newborns, and improves health and behavioral outcomes in infants.

For many mothers dealing with mental illness, navigating the healthcare system is intimidating and it can be increasingly difficult when healthcare providers are disjointed in the provision of care. Edgull also explained that there needs to be a streamlined process for follow-up between healthcare providers who offer screenings and those who offer treatment, as the system can often be disjointed. Edgull states, “There’s a phrase that we use in public health-‘Don’t screen if you can’t intervene’.

Often, unfortunately, that’s what happens, as mothers are screened for maternal mental health issues but have such infrequent visits that it can be hard to follow up.”

To this end, a research group at the University of Washington is assessing the impact and cost-effectiveness of remote consultation between providers to create a cohesive pathway for the treatment of perinatal depression in community health centers and primary care practices. For this study, researchers are using a collaborative care model for depression, which consists of placing a multi-professional provider team at each clinic. A care manager and psychiatric consultant conduct a weekly review of patients with depression review patients with depression weekly with a psychiatric consultant to create treatment plans and support the primary-care and obstetric providers. By linking social workers, mental health professional, and obstetric physicians, mothers are provided with a set of cohesive recommendations for effective treatment of their conditions.

The prevalence of maternal mental health disorders is a pressing issue within public health, and healthcare practitioners across the country are implementing novel strategies to ameliorate negative health outcomes in this vulnerable population. Historically, maternal health has fallen to the wayside in terms of national health policy priorities; but as research has shown, investing in and protecting the health of mothers and their children has vast impacts on lifelong health

“RESEARCH SHOWS THAT PAID MATERNITY LEAVE PROMOTES GREATER BONDING BETWEEN MOTHERS AND NEWBORNS, AND IMRPOVES HEALTH AND BEHAVIORAL OUTCOMES IN INFANTS.” outcomes. For this reason, lawmakers and healthcare providers should strive to address this issue through passing landmark legislation and providing early interventions to women and children who need them. 

ABOUT THE AUTHOR

Jill Litman is a fourth year Public Health major. She is passionate about issues relating to reproductive justice, such as abortion access and maternal health. Additionally, her PHA article on clinical empathy was cited as a reference in a NPR Health News piece.

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WHY YOU SHOULD WATCH YOUR SCREEN TIME While popular, late night browsing on devices can be damaging to your sleep and ultimately to your health.

BY ANNIE YANG

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ime spent on devices such as laptops and phones has increased significantly over the past few years. As the recent pandemic has forced millions to exercise social distancing at home, much of daily life has gone digital. In a recent study performed by a national parenting nonprofit, it was found that there has been a 500% increase in online time for young children in the U.S. Even before the pandemic, it was noted in the study that “the typical American already spent nearly 11 hours per day in front of digital screens.” While COVID infections pose an urgent public health problem, it is also important to consider what kinds of consequences can arise from using technological devices for more extended periods of time

“BLUE LIGHT IS ABLE TO AFFECT THE HUMAN SLEEP CYCLE BY SUPPRESSING THE LEVEL OF MELATONIN, A SLEEP-FACILITATING HORMONE, AND CAN SHIFT THE BODY’S CIRCADIAN CLOCK TO A LATER TIME.” A major concern of frequent phone and laptop use throughout the day is that people will continue overuse in the nighttime. Researchers studying light-emitting devices have found that these types of devices are generally made to emit a significant amount of short-wavelength light emissions, or blue light. This enhances the device’s efficiency and brightness during the day. As a result, if one uses their device during the evening without any sort of modification to mitigate the blue light, they are being exposed to a strong source of artificial light. A study centered around university students found that this type of device use has significant health implications. Blue light exposure during the evenings has been found to alter sleep and circadian physiology. According to the study, evidence points to associations

between blue light exposure and adverse health symptoms such as insomnia and psychiatric problems.

Blue light is able to affect the human sleep cycle by suppressing the level of melatonin, a sleep-facilitating hormone, and can shift the body’s circadian clock to a later time. These effects are useful during the day when one would need to be alert and stay awake, which is why having sunlight exposure, which contains natural blue light, can be beneficial. Whereas evening time blue light exposure will repress the amount of melatonin released at night and influence the human circadian cycle.

Dr. Allison Harvey, a UC Berkeley Professor of Clinical Psychology and Director of the Golden Bear Sleep and Mood Research Clinic, says in her recent Berkeley Talks interview, “light from the retina comes through to the suprachiasmatic nucleus, which is the seat of the circadian clock.” She goes on to explain that “the body itself is incredibly rhythmic,” which highlights that disrupting regular sleep times with blue light exposure can influence and interrupt many of the body’s important functions and cycles.

There are many temporary effects of having disrupted or insufficient sleep such as fatigue, irritability, or slower mental function, but there has also been research studying the long-term health effects resulting from poor sleep quality. Dr. Matthew Walker, a UC Berkeley Professor of Neuroscience and Psychology and the Director of the Center for Human Sleep Science, studies sleep and the related health effects in humans. In his interview on NPR, he notes that “there’s a strong relationship now between insufficient sleep and the mechanisms of Alzheimer’s disease.”

This is because sleep allows the brain to “clear out all of the detritus [waste] that’s been building up, all of the metabolic waste that’s been building up throughout the day.”

To mitigate the effects of blue light exposure on the quality of sleep, research is being done on the efficacy of blue-light-blocking (BLB) technology.

BLB glasses, made with an amber tint

“RESEARCHERS FOUND THAT ORANGE-TINTED GLASSES SIGNIFICANTLY REDUCE THE MELATONIN SUPPRESSION FROM VIEWING AN LED COMPUTER SCREEN IN THE EVENING.” that reduces the emissions of blue light to the eye, have an become increasingly popular solution. Many stores, both in person and online, offer options to purchase prescription glasses with blue-light-filtered lenses, making them widely accessible. In the study analyzing light emitting devices and the emission spectra across them, researchers found that orange-tinted glasses significantly reduce the melatonin suppression from viewing a LED computer screen in the evening. The study also found that device applications that changed colors in the evenings to a more amber tone, similar to “night-mode” or “dark-mode” on many devices, were also effective in reducing short wavelength emission.

As a result, employing any of these BLB solutions appears to be an effective, convenient, and safe way to mitigate the effects of using devices closer to bedtime. 

ABOUT THE AUTHOR

Annie Yang is a junior majoring in Public Health and Integrative Biology.

She is interested in writing about climate change, health disparities, and preventative healthcare. In her free time, she enjoys reading books, playing the piano, and baking.

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DENTAL HEALTH DURING COVID-19 Many Americans disregard oral health and dental exams. Now, the COVID-19 pandemic has amplified the dental health epidemic.

BY MAHATHI KANDIMALLA

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he COVID-19 pandemic has slowed down general healthcare checkups. People are scared, or rather cautious, to visit doctors, dentists, or optometrists.

However, the negligence in addressing health problems, especially those due to poor oral health, can lead to a new public health concern. Unfortunately, there is a limit to the number of people allowed in small, confined spaces, like dental offices.

Therefore, it is important, especially during pandemics, to recognize the importance of reprioritizing procedures, affordable care, and innovation in oral

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health.

Oral diseases are a public health concern throughout the world as they are extremely prevalent and often ignored by patients. According to a study done

by World Health Organization affiliated scientists, there are a wide range of oral health diseases from cavities to mouth cancers. Fortunately, most of these oral diseases are largely preventable.

By detecting them early, dentists can treat the condition before it turns into a painful problem. However, they are ignored due to the high treatment cost until the pain becomes unbearable.

The negligence with recognizing oral diseases creates a compounding public health issue as it leads to a plethora of economic and personal issues due to missing work, large dental bills, and a reduction in the quality of life. During a pandemic, these largely preventable diseases are even more likely to be ignored, leading to more chaos and pain.

Due to the COVID-19 pandemic, daily visits to dental offices are low and 198,000 dental offices have closed. According to Dr. Elizabeth Bertz, a Professor of preventative and restorative dental sciences at the

University of California, San Francisco, the coronavirus has “impacted every aspect of the care delivery system.” In particular, dental offices that closed during the beginning of the pandemic have struggled in opening back up. At the beginning of the pandemic dentists donated Personal Protection Equipment (PPE) to hospitals, and as they tried to reopen they faced a shortage of PPE. Additionally, according to Dr. Bertz, there has been an issue with bringing back dental office workers, especially hygienists. With 98% of hygienists being women and a lot of schools doing distance learning, many hygienists have chosen to remain home despite dental offices opening back up. With social distancing guidelines decreasing the number of patients allowed in dental

“DUE TO THE COVID-19 PANDEMIC, DAILY VISITS TO DENTAL OFFICES ARE LOW AND 198,000 DENTAL OFFICES HAVE CLOSED .” offices, and dental offices having issues opening up due to issues procuring PPE and rehiring staff, appointments have become harder to get. Therefore, for some people the lack of available appointments is preventing them from getting oral health checkups.

In some places where appointments are available, patients themselves are hesitating to go to the dental offices due to the virus and public health protocols. This decrease in daily visits leads to people not realizing they have cavities until the emergence of a severe toothache. However, simply encouraging people to go back to dentists is not a solution as this can spread the coronavirus; cleaning teeth during the pandemic is a huge safety challenge as a lot of aerosols are released during cleaning procedures.

Some dentists have been utilizing teledentistry to substitute physical visits.

However, according to Dr. Bertz, there are issues with telehealth. First of all,

it may be difficult for some patients to learn how to use new telehealth technology. Additionally, many health insurance companies do not cover teledentistry calls. Therefore, some patients are unwilling or unable to get oral health checkups via tele-dentistry.

The solution to the neglect of dental health during the pandemic comes in multiple parts. First, dental offices can mitigate the spreading of the virus by prioritizing non-aerosol releasing, more important procedures, including root canals, oral exams, and x-rays, versus teeth polishing and removing scales). As more people start coming back to dental offices, support from state and federal governments by expanding Medicaid can help get more people treated. An expansion in health insurance, even a temporary one, can help cover more people and encourage dental visits. Covering tele-dentistry can help some people get virtual checkups.

Additionally, more public health messaging to reassure people on safety measures being taken by dental offices can encourage more dental checkups.

Other federal guidance that would help provide a better framework to fight the public health issue could start with improving communication between federal, state and local governments.

Consistent messaging about the importance of oral health checkups and reinforcing safety standards will help improve oral health in the country.

While COVID-19 is a pandemic with massive repercussions, ongoing public health issues, like dental health, should not be ignored.

New vaccines are being made for the coronavirus and predictions being made on the end of the coronavirus pandemic, but the issues with dental health will continue. With many people skipping visits to the dentist, an uptick in oral health issues has been predicted during the post-corona era. Therefore, more messaging on the importance of oral health and more coverage with regards to insurance will help fix the oral health epidemic. 

“WITH 98% OF HYGENISTS BEING WOMEN AND A LOT OF SCHOOLS DOING DISTANCE LEARNING, MANY HYGENISTS HAVE CHOSEN TO REMAIN HOME DESPITE DENTAL OFFICES OPENING BACK UP. “

ABOUT THE AUTHOR

Mahathi Kandimalla is a second year intended Public Health major. When she is not attending virtual classes, you can find her biking around South-East Minnesota, recording podcasts, and reading books. She also loves to cook spicy food!

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DRIVING UNDER THE INFLUENCE

California legalized marijuana for recreational use in 2016. The state’s legal policies regarding drugged driving still remain inconclusive.

BY SONIA VAZE

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“IN TERMS OF DRUGGED DRIVING, SUPPORTERS (OF PROPISTION 64) ARGUED THAT LEGALIZATION WOULD DECREASE DUIs AND TRAFFIC ACCIDENTS, WHILE OPPONENTS ARGUED THAT THEY WOULD INCREASE.”

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heart rate, problems with coordination, heightened anxiety, and slower reaction times, which mainly stem from the THC component. A 2012 study regarding “Cannabis Effects on Driving Skills,” conducted by Hartman and Huestis, proved that driving under the influence of marijuana results in an increase in driving speed, lane-weaving, position variability and negatively impacts judgement and decision making.

When medical marijuana was legalized in California through Proposition 215 and Senate Bill 420, it established methods of regulation by mandating an identification card that verified medical marijuana patients before purchase. This legislation distinguished the governmental agencies that were in charge of monitoring consumption.

However, there was still backlash from political officials and the media about potential misuse of the drug due to gaps in legislation.

When Proposition 64 was on the ballot, intending to legalize recreational marijuana, it furthered officials’

concerns. Organizations supporting legalization included the California Democratic Party, the California ACLU, the California NAACP and Blacks in Law Enforcement of America. These supporters argued that marijuana should be decriminalized as it disproportionately affects people of color, would enable the government to have better control over the market and would result in less misuse of the drug. Additionally, they believed that tax revenue generated from the marijuana industry could be reinvested into improving rehabilitation programs and mental health facilities.

Opponents of Proposition 64 included the California Republican Party, the California Police Chiefs Association and the California Hospital Association.

Opponents argued that legalization would actually enable further misuse of marijuana by adolescents, result in an increase of public health emergencies and facilitate sales in the black market.

In terms of drugged driving, supporters argued that legalization would decrease DUIs and traffic

the legalization of marijuana continues to be a controversial issue following the “war on drugs” in America. However, California has always been at the progressive forefront of passing cannabis laws. In 1996, California became the first state to legalize marijuana for medical usage, and it was the fifth state to legalize it for recreational use in 2016. Four years later, the state’s legal policies regarding drugged driving still remain inconclusive due to a lack of understanding on how legalization has impacted road safety. Recent studies provide insights concerning the correlation between DUIs, traffic accidents, and the legalization of recreational marijuana.

Marijuana, colloquially known as “weed” or “pot,” is a drug produced from the plant Cannabis sativa. It contains two major components: Cannabidiol (CBD) and Tetrahydrocannabinol (THC). CBD is the non-psychoactive chemical that is commonly used in medicine for treating anxiety, depression, insomnia, and chronic pain. On the other hand, THC is the main psychoactive compound in marijuana that produces the sensation of a “high.” According to Dr. Bruce Bagheri, a California cardiologist, “marijuana can essentially alter your level of consciousness and it affects how you drive.”

“Driving under the influence” (DUI) of any substance, including alcohol and marijuana, is considered a criminal offense. Marijuana is the most commonly found drug in the bloodstream of individuals involved in car accidents. MARIJUANA FARMS in California have grown in number since the passage Side effects from marijuana that could of Proposition 64. Santa Barbara County and Humboldt County hold the negatively impact driving are increased most cultivation licenses across all counties in the state.

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accidents, while opponents argued that they would increase. Now that California is four years post-legalization, we can attempt to understand and examine exactly which claim the data supports.

Unfortunately, there has been conflicting evidence. Studies conducted in states that have legalized marijuana since 2012, such as CO and WA, provide data that is available and applicable. In California, although marijuana was legalized in 2016, the practice of purchasing cannabis didn’t start until 2018, leading to a lack of sufficient data on DUIs and traffic accidents within that time frame.

A 2018 article titled, “Legalized Marijuana Linked to a Sharp Rise in Car

“CALIFORNIA DOESN’T HAVE A STATUTE OR ‘PER SE’ LIMIT ON THE AMOUNT OF THC ALLOWED IN THE BODY WHILE DRIVING.” Crashes” from NBC news, examined police reports and insurance claims from all states that have legalized recreational marijuana. They found that traffic accidents rose about 6% collectively in states that had legalized recreational marijuana, relative to states that had not. Additionally, a 2019 article by the Orange County Register indicated that “drug-related DUI cases nearly quadrupled in Los Angeles County” after comparing cases in 2017 to 2018, when retail sales of marijuana began in California. Contradictingly, a 2020 USA Today article demonstrated that, although California indicates an increase in drugged driving during fatal vehicle accidents, they have had 8.3% fewer traffic fatalities in 2018, compared to 2017. As reported, the data sends mixed messages; some studies show an increase in traffic accidents correlating to DUIs, while others show a decrease in California’s post-legalization era. What makes these findings even more ambiguous is that DUI data considers drugged driving incidents collectively, not exclusive to marijuana. They studied data in 2018,

16 | FALL 2020

when retail sales of marijuana began, and compared it to previous years, but there’s no solid evidence we can utilize to confirm whether those results were caused after legalization.

Although there haven’t been many definitive results on DUIs in California post recreational legalization, the lack of sufficient data is most likely attributed to the inability to test and ambiguous police reporting of DUIs. Unlike alcohol or other illegal narcotics, marijuana accumulates in the body’s fat cells, which means that cannabis can stay in one’s bloodstream for an extended amount of time after the effects wear out. Factors such as potency, gender, age, and method of use also affect how fast marijuana is metabolized. According to Dr. Marilyn Huestis, a toxicologist and expert on drug testing, “it generally takes women longer than men to filter marijuana out of the system and blood levels of THC can increase over time if people were physically active.”

As a result, there is no comparable tool, like a breathalyzer -- which tests for blood alcohol content (BAC) - for obtaining immediate and definitive results for the presence of marijuana in human systems. According to the Kraut Law Group, based in California, “the police must actually prove that the driver was under the influence of Marijuana and not merely rely on the results of chemical testing.” The only way to confirm driving under the influence of marijuana is to complete a blood or urine test. According to California driving laws, the principle of implied consent asserts that, “if lawfully arrested for a DUI, any person who drives a motor vehicle on the roads of California is deemed to have given their consent to chemical testing of their blood or urine for the purpose of determining drug contents.”

However, even if there was such an instrument similar to a breathalyzer, California doesn’t have a statute or “per se” limit on the amount of THC allowed in the body while driving. Other states that have legalized recreational marijuana have adopted limits ranging

“IT IS EVIDENT THAT CALIFORNIAN LEGISLATORS MUST TAKE ACTION IF WE HOPE TO SEE ACCURATE AND SPECIFIC DATA COLLECTION IN THE FUTURE.” from 0.5 to 5 nanograms/milliliter.

Furthermore, in California, when police file drugged driving reports, their documentation doesn’t distinguish between being under the influence of marijuana versus other illegal narcotic drugs. As a result, when drugged driving cases are analyzed specifically for marijuana usage, the data is misleading.

California has been a unique case in the controversy of legalizing recreational marijuana. Officials are still in the beginning stages of analyzing data to confirm the impact legalization has on DUIs and traffic accidents.

However, it is evident that Californian legislators must take action if we hope to see accurate and specific data collection in the future. The state also needs to develop a more reliable and efficient method for testing THC levels, adopt a “per se” limit for THC blood levels while driving and give law enforcement the ability to distinguish DUIs of marijuana exclusively. 

ABOUT THE AUTHOR

Sonia Vaze is a sophomore intending to double major in Public Health and Molecular Cellular Biology and is passionate about exploring the intersections between medicine, policy, and research within the healthcare field. In her free time, she loves to watch movies, play board games, and travel.

BIDING TIME FOR BIDEN

BY AMY RICH

Democratic presidential nominee Joe Biden pledges to build upon the Affordable Care Act. But how do his health care plans compare to Sanders’?

THE PUBLIC HEALTH ADVOCATE | 17

T

he 2020 election season is drawing to a close, and as television screens daily illuminate with political news every day, Americans listen to the Republican and Democratic parties’ unique versions of various policy goals. After a passionate primary race among the Democratic candidates, president-elect Joe Biden prevailed as the nominee for the Democratic party. Despite this, the controversies contested by the candidates throughout the Democratic debates remain relevant even after election season. One controversy — whether healthcare is a human right or a commodity — debates whether healthcare is a need that should be regulated by the government or a choice that should be regulated by the marketplace through supply and demand.

While the Democratic candidates offered contrasting healthcare policy goals, this article focuses on two Democratic candidates in the race, Bernie Sanders and Biden. Democratic candidate Bernie Sanders, before conceding the final Democratic nominee spot to Biden, fought for universal healthcare. Biden, a more centrist Democratic candidate, advocates for individuals’ rights to decide their own healthcare plan. While Sanders and Biden advocated for health justice and health coverage for all, their plans differed in significant ways and posed varying financial and health-related implications.

Sanders’ “Medicare for All” campaign proposed a single-payer, national health insurance program that would provide Americans with comprehensive health care coverage, while Biden argues that those who prefer an alternative to Medicare should be able to choose a separate or a private insurance plan.

Both Sanders and Biden agree that the consolidation of pharmaceutical companies, health insurers and hospitals has increased prices without improving the quality of health services. In fact, “the global pharmaceuticals market was worth $934.8 billion in 2017 and will

18 | FALL 2020

reach $1170 billion in 2021, growing at 5.8%,” according to a recent pharma market research report by the Business Research Company. Sanders explained that while the average American pays an excessive amount for premiums, deductibles, copays, and other outof-pocket expenses, the wealthiest one percent of Americans and multimillionaires pay little in taxes. In response to the pharmaceutical industry, Bernie Sanders’ plan proposed a one percent tax on individuals who make $32 million in income and up to an eight percent tax on individuals who make over $10 billion. This separate wealth tax, in addition to tax increases on both large businesses and the wealthiest individuals in the country, would have funded Sanders’ healthcare plan, saving middle-class Americans from the need to pay additional taxes.

Although Biden does not advocate for a separate wealth tax, Biden explains he will fund his healthcare plan by raising the country’s top individual income tax rate from 37 to 39.6 percent and the corporate tax rate from 21 to 28 percent, according to the Tax Foundation website. Similarly, Biden’s healthcare

plan would not only be funded through corporate taxes and spending cuts but also through the money gained by the breakdown of the pharmaceutical company conglomeration. Broadly speaking, Sanders’ plan for Medicare for All favored taxing big, wealthy businesses, as well as eliminating forprofit pharmaceutical corruption, while Biden stands behind former President Barack Obama’s Affordable Care Act and affirms that building on the ACA, in addition to giving Americans a choice, will reduce healthcare costs and increase healthcare coverage.

Bradley Heinz, a joint graduate student at the Berkeley School of Public Health and joint medical student at the University of California, San Francisco, is a member of the Students for National Health Program (SNaHP)—an organization that advocates for singlepayer health insurance. Since learning about health disparities in the U.S. through an article he read in a public health course called “Improving the Prognosis of Health Care in the USA”

by Galvani et al., Heinz says that health disparities in the U.S. are primarily driven by a lack of access to healthcare.

BERNIE SANDERS promotes his “Medicare for All” plan at a campaign rally in Pittsburg, PA in April 2019.

According to the article, “40 million Americans remain uninsured, 70,000 people will needlessly die, and 500,000 to one million people will go bankrupt” due to our current health insurance plan.

On a different note, primary care physician Dr. Phyllis Cohen supports Biden’s healthcare plan in its vows to increase access to the nation’s mental health services; such health issues are often overlooked and are in urgent need of improvement, according to Cohen. In “all tiers of medicine, mental health services are lacking, which makes practicing medicine very difficult, since much of health improvement is based on behavior changes and a sense of wellbeing. Mental health services are key but are often not available,” Cohen said.

“BIDEN AIMS TO ‘REVERSE THE HYDE AMENDMENT AND INCREASE FUNDING TO PLANNED PARENTHOOD TO ASSURE THAT WOMEN HAVE FULL ACCESS TO REPRODUCTIVE CARE’ ” In addition to expanding the nation’s mental health services, Biden aims “to reverse the Hyde Amendment and increase funding to Planned Parenthood to assure that women have full access to reproductive care.”

The Hyde Amendement is a legislative provision that “blocks federal funds from being used to pay for abortion outside of the exceptions for rape, incest or if the pregnancy is determined to endanger the woman’s life, resulting in dramatically limited coverage of abortion under Medicaid and other federal programs,” according to KFF. In contrast, Trump proposed that his 2021 budget would decrease total funding toward substance abuse, mental health services and Medicaid, claimed that his administration’s goal is to overturn the Affordable Care Act altogether, and called for the Hyde Amendment to become permanent law.

Like Biden, Bernie vouched for comprehensive reproductive care under

Medicare for All that would repeal the Hyde Amendment; “all reproductive health services [would] be provided free at the point of service,” including contraception, according to the Bernie Sanders Official Website. Dr. Cohen says that because Biden is the more moderate Democrat, he has the potential to more widely connect with moderate Americans who may not hold such frequent conversations around those issues of mental health and reproductive rights. Therefore, Biden’s plan works to address communities in America that have often been overlooked or excluded from the healthcare conversation and encourages moderates to place importance on mental and reproductive health issues in the healthcare debate.

While Heinz agrees with the importance of addressing the nation’s mental health and women’s rights issues, he says a combination plan like Biden’s would exacerbate tiered care based on socioeconomic status. As a result of such considerations, Heinz advocates for Bernie’s healthcare plan due to its financial benefits for Americans.

Sanders’ single-payer system advocated would have saved “billions annually, eliminate medical bankruptcies, [provided the] greatest relief to lower income households, and [offered the] highest quality medical care for all,” Heinz said. As “insurance status is one of the main socioeconomic determinants of health,” access to primary care via a single-payer system can sustain the health of Americans, according to Heinz.

Americans’ votes in the presidential election have determined the direction of the healthcare debate going forward.

President-elect Joe Biden faces the task of repairing a healthcare system in America that has historically created high prices for health services and left many Americans uninsured. Although healthcare impacts the country as a whole, Berkeley students and young voters may have reasons other than healthcare that motivates them to vote during election season. Despite this, long-term reform goals like healthcare plans take years to implement and require informed citizens and voter and

“LONG-TERM REFORM GOALS LIKE HEALTHCARE PLANS TAKE YEARS TO IMPLEMENT AND REQUIRE INFORMED CITIZENS AND VOTER AND CIVIC ENGAGEMENT TO ACHIEVE CHANGE” civic engagement to achieve change.

The healthcare debate will not near an end any time soon, but citizens, as well as Biden, can learn from the various healthcare goals and strategies of the previous Democratic candidates, strive to implement their ideas into a healthcare plan that prioritizes high quality, not-for-profit health insurance coverage for all Americans and work to restore the democratic values that have crumbled alongside the rates of health in our country. 

ABOUT THE AUTHOR

Amy Rich is a third year majoring in public health and minoring in public policy. In her free time she loves to thrift shop, hang out with friends, hike, and watch movies.

THE PUBLIC HEALTH ADVOCATE | 19

HIV AND THE DEEP SOUTH Stigma and lack of visibility drive discriminatory policy in rural America. How has this impacted HIV burden?

BY MIKKEL NAGORSEN

T

he Deep South is home to about a quarter of the population of the United States, yet the nine states that make up this region (FL, AL, MS, GA, TX, LA, TN, SC, NC) accounted for more than forty percent of new HIV diagnoses in 2017. Nine of the ten U.S. metro areas most affected by HIV are in this region; so are eight of the ten most affected states. People living with HIV in

20 | FALL 2020

the Deep South die at higher rates than their Northern or Western counterparts.

Such an overrepresentation does not arise out of thin air. Many intertwined issues that have historically plagued the Deep South combine with a religious conservative culture to create the harsh realities of HIV in the region.

According to Elena Wilson, M.P.H., who studies HIV and its impact on

the Deep South at Duke Global Health Institute’s Center for Health Policy and Inequalities Research, the biggest difference between living with HIV in the Deep South and other regions of the United States is stigma. She recounted instances of discrimination that she described as unthinkable in other parts of the country. These included examples of people living with HIV being treated

as if they were highly contagious - the house being cleaned with Lysol after visits, being made to eat off paper plates - or being yelled at in the street. Wilson explained that people and families also often do not talk about HIV, which causes people living with HIV to feel isolated.

This stigma has a profound impact on health care outcomes in the Deep South.

Increased stigma is associated with lower medication adherence, an unwillingness to disclose HIV status to sexual partners, as well as lower rates of testing, which all lead to poorer outcomes for individuals and the population as a whole. Wilson identifies increased visibility as a major factor that would improve the lives of people living with HIV in the region. She would like to see celebrities taking HIV tests, or billboards being erected in rural areas. Other options include educational programs that bring together people who hold stigma and people living with HIV. This option is “really effective to put a face on [people living with HIV], especially for people who may not have a lot of contact,” says Wilson.

“PEOPLE LIVING WITH HIV HAVE BEEN PROSECUTED FOR BITING OR SPITTING - ACTIONS THAT CARRY NEGLIGIBLE RISK OF HIV TRANSMISSION.” Stigma is made into policy through HIV discrimination laws. These laws were originally intended to prevent people purposely spreading HIV, says Wilson. People living with HIV have been prosecuted for biting or spitting - actions that carry negligible risk of HIV transmission. Wilson is worried by the fact that these cases are often heavily covered by newspapers, leading to misinformation about HIV and HIV transmission spreading. Other policies that worsen the Deep South’s HIV burden are abstinence-based sex education (which has proven to be ineffective in preventing the spread of STIs) and a lack of support for needle exchanges.

The struggles of people living with HIV in the South are compounded by many issues that face the region as a whole. Poverty and unemployment in the Deep South are higher than anywhere else in the country, both of which are associated with poorer health and higher death rates. Rates of health insurance are also low, and Louisiana is the only state in the region that has expanded Medicaid, which leaves larger Medicaid gaps in the remaining states.

The Deep South is also the most rural area in the United States and has the highest proportion of rural people living with HIV, which brings with it unique challenges. These challenges lead to even worse outcomes for people living with HIV, such as more progression to advanced stages of HIV and higher mortality. People in rural areas often have to drive long distances to see a healthcare professional who is able to help them. There is also less access to public transit and fewer social services in general. Rural populations also often face more stigma and feelings of isolation, says Wilson, especially if there are only a few people with HIV in the county. This is concerning to Wilson as it leads people to not use the care options and services that may oftentimes be available to them.

Rural populations are not the only group that is in an especially difficult position. Black men who have sex with men made up almost a third of all new diagnoses in 2017. Nearly all the problems that face the general population, such as poverty and unemployment are compounded for this group. However, they also face problems that other populations do not face. Mass incarceration of black men, for example; according to Wilson, incarceration can easily disrupt treatment. The saturation with HIV is also especially high, as Wilson put it, “if you’re a black man who has sex with other men in the South and your condom breaks one time you are much more likely to get HIV than you would be somewhere else in the country.” This saturation is caused by factors beyond the control of individuals. Wilson also explained that

black men who have sex with men often “have to come out again and again,” as gay and as HIV-positive, which can be traumatic. Through being who they are, black men living with HIV who have sex with other men, face stigma and discrimination for their race, their sexuality and their HIV status.

Despite all these challenges, Wilson is optimistic. “There are just so many organizations doing really, really amazing work … working in this grass roots way,” and she is excited about increased visibility. While financial help to organizations in the South is good, Wilson says that the best way people outside of the South can help is by engaging with, highlighting and increasing the visibility of HIV through participating in campaigns that are happening online - “anytime you can spread information that is correct you are doing something huge.” 

ABOUT THE AUTHOR

Mikkel Nagorsen is a first-year student at UC Berkeley in the College of Letters and Sciences. He grew up in Germany and Thousand Oaks, CA. He enjoys reading, spending time outdoors with friends, and learning about anything and everything.

THE PUBLIC HEALTH ADVOCATE | 21

POLITICAL POLARIZATION AND PUBLIC HEALTH The unlikely combination resulted in severe consequences for policy formation and legislation, especially regarding the government’s response to COVID-19.

BY AMMAR BHAIJI

T

he American political environment over the past decade or so has become increasingly more volatile and delicate.

With the rise of disinformation campaigns and increasing distrust of people with different political beliefs of our own, our country’s political system doesn’t function properly. One doesn’t have to look farther than the 2020 Presidential Debates. In the first debate, rather than discussing meaningful policy ideas, former Vice President

“POLITICAL POLARIZATION IS THE POLITICAL DISTANCE SEPARATING PARTISANS, AND IT HAS ONLY GROWN.” 22 | FALL 2020

Joe Biden and incumbent President Donald Trump instead engaged in a verbal shouting match with insults thrown. This political polarization and the associated tribalism has massively impacted the United States’ ability to adequately respond to and mitigate the effects of the COVID-19 pandemic.

Political polarization is the political distance separating partisans, and it has only grown since 1994, according to the Pew Research Center. However, polarization in our political system has been around since the 1960s, when conservative Southern Democrats started to see their party drift away from their beliefs and ideals, as UC Berkeley Political Science professor Eric Schickler notes. He also said that around this time, political scientists were calling on the parties to be more “responsible,” but

their opinion was largely disregarded by the national Democratic and Republican parties. There are a number of reasons as to why we perceive the other side as “the enemy,” but some of the main causes include a decline of journalistic responsibility, growing racial and religious diversity, geographical sorting (wanting to live in areas with people that think like us and have similar beliefs), and increasing implementation of binary thinking (either/or), motivating logic (trying to fit evidence to a narrative), and seeking approval from our “tribe.”

More specifically, tribalism, or our predisposition towards protecting a group we are a part of, or “tribe,” is one of the main factors that is pulling liberals from conservatives and inciting mutual hatred leading to our political polarization.

At its very core, tribalism is a psychological survival instinct wired in our brain from our beginnings, as noted by Terri Bimes, a political science professor at UC Berkeley. There is inherent safety in having others to “watch your back” whether it be on a night out on the town or out in the wilderness.

This advantage is so highly sought after, that we are willing to do anything to maintain our connection with our “tribe.”

This includes conforming to ideas set out by leaders of the group, as Christopher Gade, professor of psychology at UC Berkeley notes: “Conformity can take many forms and one of the most common mechanisms by which it’s achieved is through something called public compliance, where members of a group will subscribe to ideas to show allegiance to their group.” This same phenomenon manifests itself with political parties and regular voters who may be scared to be characterized as unfaithful to their party.

These attitudes have severe consequences for policy formation and

“THE UNITED STATES HAS ONE OF THE WORST OUTBREAKS OF COVID-19, PARTLY BECASUSE OF AN INADEQUATE FEDERAL GOVERNMENT RESPONSE.” for legislation, especially when it comes to issues that require a quick and strong response. One prominent example of political dysfunction is the government’s response to COVID-19, and how tribalistic attitudes have hampered the country’s response to COVID-19. With 6.5 million confirmed COVID-19 cases and counting, the United States has one of the worst outbreaks of COVID-19, partly because of an inadequate federal government response.

However, it would be inaccurate to blame the United States’ failure to contain the virus entirely on the federal level, as the population is also partially to blame for the spread of the virus.

There are a plethora of steps that can be

taken to mitigate the spread of the virus, including avoiding crowded spaces, sanitizing surfaces that are frequently touched, and wearing a mask. Wearing a mask can prevent the transmission of your own microscopic droplets while also preventing other respiratory droplets that may contain coronavirus particles from entering your nose and mouth. Mask-wearing in the United States, unfortunately, has fallen prey to tribalism and political tendencies.

Democratic governors have largely put in place widespread mask mandates, while their Republican governors have been hesitant to institute those same orders, cognizant of the fact that their constituents see masks as an infringement of their civil liberties.

With this, citizens of both parties have adopted their various party’s positions on wearing masks, in accordance with our tribalistic tendencies that are increasingly taking over our everyday lives. In this way, refusing to acknowledge the fact that this crisis is about the human race rather than a certain political party, we have allowed the United States to make the pandemic another partisan issue. In this sense, by allowing basic public health and safety to be overshadowed by our political tribes and our tribalistic attitudes, as a country, we have lost ourselves.

All hope is not lost. There are still politicians and candidates on both sides of the aisle that are fed up with the divisive nature of our politics, especially when it comes to tackling large, nonpartisan problems like the COVID-19 pandemic.

While political polarization is a large problem in our country, it is not one we cannot overcome. It will require blood, sweat and tears to purposefully seek out those with a different political view in order to start a dialogue about where our country should be headed. It will require us all to try and understand people’s perspectives. It will require us to show up at the polls and on the streets to demand legislation that would dilute the influence of dark money in politics, eliminate gerrymandering and voter suppression and fundamentally

“THERE ARE STILL POLITICIANS AND CANDIDATES ON BOTH SIDES THAT ARE FED UP WITH THE DIVISIVE NATURE OF OUR POLITICS... WHILE POLITICAL POLARIZATION IS A LARGE PROBLEM IN OUR COUNTRY, IT IS NOT ONE WE CANNOT OVERCOME.” reshape the way elections are run. Most importantly, it requires us to have hope that we can change our country’s political climate for the better. 

ABOUT THE AUTHOR

Ammar Bhaiji is a second-year intended Public Health major minoring in Public Policy. He is interested in health policy and hopes to attend medical school. In his free time, Ammar enjoys camping, mountain biking, and watching documentaries on assorted topics.

THE PUBLIC HEALTH ADVOCATE | 23

THE RACIST PAST OF KIDNEY SCREENING Should race be a factor in determining who gets a kidney translant?

BY FIRDOWS MUJIR

U

CSF made headlines last year after a landmark decision to remove the factor of race from all of the kidney screening procedures at Zuckerberg San Francisco General Hospital. The decision was influenced by a recent spark in discussion of race in medicine following an article by New England Journal of Medicine analyzing the use of racial bias in various medical procedures, including kidney testing.

The current procedure for kidney function testing measures the levels of creatinine in the patient’s blood, or waste products, and this value is used in a formula to find the patient’s estimated glomerular filtration rate (eGFR),

24 | FALL 2020

which is how fast the kidneys filter blood. eGFR is then classified to be low, normal, abnormal, or abnormal critical.

This classification is determined by comparing the value for eGFR to the set range of values for each level of function determined to the patient’s age, gender, body size, and race. It is understandable that an adolescent patient and a geriatric patient would have different levels of kidney function that would be considered healthy, or a man versus a woman. But why was this logic applied to race as well?

Historically, eGFR was calculated using the Cockcroft-Gaft formula. This formula was developed in 1973 by using

data of creatinine levels in 250 men, and utilizes age, gender, and body weight alongside creatinine values to calculate a eGFR. In the 1990s, however, it was noted that this formula underperformed in determining creatinine levels in black patients. This lack of accuracy was, at

“NOT BEING QUALIFIED FOR A KIDNEY TRANSPLANT MEANS A PATIENT MAY HAVE TO LIVE WITH A DEFUNCT KIDNEY BASED ON AN ARBITRARY STANDARD”

the time, attributed to the formula’s lack of distinction between lean body weight, or weight not including fat mass, and ideal body weight, which includes both.

Thus, in 1999, the MDRD and CKIEPI formulas were established and became the standard for measuring kidney function. These formulas corrected for Cockcroft-Gaft’s faults by taking the patient’s muscle mass into consideration. While surveying this consideration, the MDRD study surveyed that black patients had higher creatinine levels, thus race was added

“THE CORRELATION FOR RACE BASED ON MUSCLE MASS APPEARS TO BE BASED MORE ON THE RESEARCHERS’ IDEOLOGIES OF BLACK PATIENTS RATHER THAN REALITY.” to further correct the formula for measuring eGFR, with the assumption that black patients had higher muscle mass due to their race. The kidney function score for black patients was multiplied by 1.212 before being compared to standardized measures of what is considered normal or abnormal. However, this correction for race based on muscle mass appears to be based more on the researchers’ ideologies of black patients than than reality. On the issue, Dr. Vanessea Grubbs, a nephrologist at San Francisco General Hospital, says in her article “Precision in GFR Reporting,” that this “effectively impl[ies] that blacks are biologically distinct from all other humans.”

To combat this, a study done at UC Davis in 2008 aimed to investigate this long held claim by attempting to find an association between body composition, or levels of muscle mass, and creatinine levels in over 3000 patients, about 50% of whom were black. Though the study did find that the creatinine levels in black patients

were higher than non-black patients, there was no association found between these values and muscle mass of the patients. Looking back, MDRD formulas’ basis for giving black patients more normal eGFR rates was due to a flaw in the study’s design; the set of participants in the study had less than 200 black patients, and this underrepresentation is thought to have led to an inaccurate set of data. The legacy of this flawed data and formula has continued impacts on the lives of black kidney patients.

Under the MDRD and CKI-EPI formulas, black patients and non black patients are measured based on two different standards. These standards determine what levels of creatinine are healthy for the individual, and use race to make the standard more precise. Dr. Grubbs explains that “no matter if one is 51%, 78%, or 22.56% of a race—a simple yes or no for “if black” appears to be all the precision we need.” For a non-black woman that is 55, a 2.8mg/ ml level of creatinine qualifies them to need a kidney transplant. For a black woman of the same age with the same concentration of creatinine, they would not qualify for a transplant.

This change in formula directly results in a change in quality of care, and subsequently quality of life for the patient. Not being qualified for a kidney transplant means a patient may have to live with a defunct kidney based on an arbitrary standard. This may leave many people falling through the gaps of patient care, which is a persistent problem in healthcare for black communities.

This formula also badly accounts for other racial groups. Studies from India, Japan and Pakistan suggest that the measured average GFR for individuals in these regions is lower than estimated for these using the CKD-EPI equation for whites. The study behind the CKD-EPI formula also states that these differences were geographical and ethnic rather than based on race, thus using race as a heuristic is less than ideal.

Though the specific solution to measuring kidney function accurately is not yet clear, it is clear that transitioning

“IT IS CLEAR THAT TRANSITIONIING AWAY FROM THE CKD-EPI FORMULA WAS A MUCH NEEDED CHANGE” away from the CKD-EPI formula was a much needed change. It also has become clear that this is not the only area of medicine that is affected by prominent racial differences, as similar issues have been reported within cardiology and obstetrics. Medical racism is an issue at the forefront of public health, and we must continue to analyze the mistakes in science of the past to create a healthier future for everyone. Dr. Grubbs says, “Let’s stop playing the race card like it’s a genetic marker. It simply is not.” 

ABOUT THE AUTHOR

Firdows Mujir is a third year MCBNeurobiology major who is also pursuing a minor in Bioengineering. She is from Minneapolis, Minnesota and enjoys spending her free time cooking and being in nature. She hopes to pursue a career working with biomedical devices or in medicine.

THE PUBLIC HEALTH ADVOCATE | 25

SUICIDE PREVENTION IN VETERANS After combat, veterans face a new battle against suicide ideation.

BY ALISHAH KHAN

26 | FALL 2020

V

eterans have a unique job description: many have put their lives at risk every day doing field work, handling firearms and engaging in combat. One task not listed in the description? Wrestling with suicidal thoughts.

Suicide is one of the leading causes of death in the United States. According to NIMH, 85% of adults who attempted suicide were found to have suicide ideation. Suicide ideation is defined as thinking about or planning suicide.

Because of their past experiences as military personnel, veterans are especially at risk for suicide ideation, causing them to be more likely to commit suicide than other demographics. With the average number of suicides per day by veterans on the rise from 15.9 in 2005 to 16.8 in 2017, it is more important than ever to ask why veterans are such an at-risk population, and what we can do to prevent such high rates of suicide among this vulnerable group.

Matthew Nock, professor of psychology at Harvard University, has been working to answer these questions.

When asked what factors make veterans such a vulnerable population, Nock replied, “there is no silver bullet, but a constellation of factors. It is difficult to know which factors are causal and have the biggest impact.” According to Nock, a sense of disconnection, loss of camaraderie, mismatch of mentality, disconnection when coming back into society, as well as a lack of connection with services contribute to higher risk for suicide ideation in veterans.

Although it is easy to assume PTSD or memory of combat takes enough of a toll on every veteran to directly cause suicide ideation, risk factors in veterans are in fact very similar to risk factors in civilians and service members. Legal problems, relationship problems, and substance abuse, which veterans are more susceptible to, are all common risk factors for suicide ideation in veterans.

It is the problems associated with the transition from a military lifestyle to a civilian lifestyle that contribute most to suicide ideation in veterans.

The Veterans’ Association clearly recognizes the need for programs to support veterans and lower risk for suicide attempts. It lists a number of mental health programs meant to support military personnel after their time of service; offerings include an online self-help portal under the Veteran Training program, a smartphone app to track daily habits, a “telemental health” program, and the option to speak to a fellow veteran who has struggled with mental health in the past. Veterans have the option to seek help online, over the phone, or in person. Some services, such as the telemental health program, are available 24 hours a day, 7 days a week.

So why is it that 2/3 of veterans who die of suicide are not connected with Veterans’ Association services, which are so seemingly accessible?

One common trait among these programs stands out above all others: the fact that they are optional. A clear absence of mandatory mental health screening or treatment after service leaves many veterans to fend for themselves when experiencing suicide ideation. Programs set up by groups like the Veterans Association may never reach the individuals they are meant to help, even though they could be vital in preventing suicide ideation as well as suicide attempts. Veterans are in desperate need of mandatory, rather than optional, post-service programs that will screen or predict their likelihood of falling into suicide ideation.

Nock recognizes this need, and he has a solution in mind. Machine learning, he says, will be the answer to predicting risk for suicide in veterans. “A clinician will ask questions about depression, suicide, and substance abuse, but the human brain is not equipped to assess the risk factors just because there is a combination of so many different risk factors. Machine learning helps combine all the different factors.” Now that health information is largely on an electronic record, it is possible to use machine learning to build statistical models, which can predict whether someone will attempt suicide. These statistical models

can handle up to 3 dozen or more factors, making predictions more accurate than any human could. Although these models started out by using numeric code to create prediction models, they now use natural language processing to comb through doctor’s notes for certain keywords. These flagged keywords may lead to indicators of suicide ideation.

In addition to machine learning, clinicians rely on behavioral tests to detect suicide ideation in an individual.

For example, a patient may be given an implicit association test, where they are asked to associate concepts with each other in a timed environment. By measuring and analyzing reaction time to each of the questions, clinicians can look at patterns to see if the individual may be at risk for suicide ideation.

With the need for mandatory screening growing as the suicide rate in veterans increases, incorporating machine learning-based statistical models and implicit bias tests into the discharge is more important than ever. The Veterans’ Association must recognize this need and work with the US Armed Forces to take more upstream approaches to suicide prevention and mental health before we lose more of this vulnerable population. 

ABOUT THE AUTHOR

Alishah Khan is a second year studying public health and public policy. She is passionate about infectious disease research, discovering disparities in healthcare policy, and Boston sports teams. Outside of class, you can find her taking pictures of the beautiful views on campus or on a run.

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